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ICD-10 High Level Overview For Practice Managers OPA October 6 th, 2013 Presented by Margie Scalley Vaught CPC, CPC-H, CPC-I, CCS-P, MCS-P, CCP, ACS-OR,

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Presentation on theme: "ICD-10 High Level Overview For Practice Managers OPA October 6 th, 2013 Presented by Margie Scalley Vaught CPC, CPC-H, CPC-I, CCS-P, MCS-P, CCP, ACS-OR,"— Presentation transcript:

1 ICD-10 High Level Overview For Practice Managers OPA October 6 th, 2013 Presented by Margie Scalley Vaught CPC, CPC-H, CPC-I, CCS-P, MCS-P, CCP, ACS-OR, ACS-EM 1

2 Disclaimer The purpose of these handouts is to accompany the presentation conducted by Margie Scalley Vaught, and sponsored by MGMA OPA. It is only a supplemental workbook and is not a substitute for the CPT-4 or the ICD-9-CM coding manuals. There is no guarantee that the use of this publication will prevent differences of opinion with providers or carriers in reimbursement disputes. Margie S Vaught, or any third-party sponsor provide nor implied or expressed warranty regarding the content of this publication or seminar due to constant changing regulations, laws and policies. It is further noted that any and all liability arising from the use of materials or information in this publication and/or presented at a seminar is the sole responsibility of the participant, and their respective employers, who by his or her purchase of this publication and/or attendance at a seminar evidences agreement to hold harmless the aforementioned parties, their employees and affiliates. The intent of this publication is to be used as a teaching “tool” accompanying the oral presentation only. 2013Edition ©All rights reserved. No part of this publication may be reproduced in any form or by any means without the express written permission of the publisher. Seminars and their material are protected by copyright. 2

3 Objective During this session we will help practice leaders identify areas needing attention as we prepare for ICD-10 usage. Such areas discussed will be the work flow situation – Who will be responsible to make sure the correct ICD-10 code(s) get selected for the encounter; – Can superbills/encounter forms/cheat sheets be helpful and if so tips on putting these together for the Orthopedic Practice; We will also discuss how to get the physicians on board using their specialty society AAOS as a pressure point! Last but not least, how can you start TODAY to get this ICD-10 transfer to go smoothly and without as much drama and pain as some are stating. 3

4 4

5 Basic Info Practice Managers Need to know 5

6 ICD-10 Introduction In January 2009, the federal government determined the U.S. would upgrade to the 10 th revision of the ICD as of October 1, 2014. – ICD-10-CM (Clinical Modification) Used to assign diagnosis codes A clinical modification of ICD-10 developed by the National Center for Health Statistics (NCHS), a division of the Centers for Disease Control and Prevention (CDC) – ICD-10-PCS (Procedural Coding System) Unique to the US and independent of ICD-10, but designed to complement the structure of ICD-10 Developed by the Centers for Medicare and Medicaid Services (CMS) with 3M’s health information systems division Used to assign procedure codes for the inpatient setting 6

7 Delay until 2014 CMS has confirmed that ICD-10 will take effect October 1, 2014 No more delays 7

8 ICD-10 Implementation No Grace Period – Providers will NOT be able to report ICD-9-CM codes For services on or after October 1, 2014 No Delays – No delays in the implementation date for ICD-10 8

9 Benefits to ICD-10-CM/PCS Reduced ambiguity Enhanced system flexibility for adding new codes Better reflection of current medical terminology and technology Expanded detail relevant to ambulatory and managed care encounters Data transparency for reimbursement and compliance efforts Incorporation of recommended revisions to ICD-9-CM that could not be accommodated HIPAA criteria for code set standards are met (5010) Improved collection and tracking of new diseases and technologies Space to accommodate future expansion 9

10 ICD-10 Implementation ICD-10 vs. ICD-9 Codes – Provide greater diagnoses and procedures description details – Greater number of ICD-10 codes than ICD- 9 codes – Longer and use more alpha characters – Requires system changes to accommodate new codes 10

11 ICD-10 Implementation ICD-9-CM – 3-5 characters 1 – Alpha or Numeric 2-5 – Numeric Always 3 characters Decimal after 3 rd character ICD-10-CM – 3-7 characters 1 – Alpha (‘U’ NOT used) 2 – Numeric 3-7 – Alpha or Numeric Decimal after 3 rd character Dummy placeholder ‘X’ Alpha characters NOT case-sensitive 11

12 ICD-10-CM/PCS Growth of Codes DiagnosisProcedure 12

13 Why So Many Diagnosis Codes? Greater specificity and detail: – 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system. – 17,045 (25%) of all ICD-10-CM codes are related to fractures. – 10,582 (62%) of fracture codes distinguish right from left. – 25,000 (36%) of all ICD-10-CM codes distinguish right from left. 13

14 ICD-10 Implementation Version Updates – Annual updates of ICD-10-CM & ICD-10-PCS posted on the ICD-10 website – Maintenance and updates of ICD-9-CM and ICD-10 are discussed at the ICD-9-CM Coordination and Maintenance (C&M) Committee meeting Codes/03_meetings.asp Codes/03_meetings.asp 14

15 ICD-10 Implementation General Equivalence Mappings (GEMs) – Assist in converting data from ICD-9-CM to ICD-10 – Forward and backward mappings Information on GEMs and their use – Description of MS-DRG Conversion Project – – GEMs NOT a substitute for learning how to code with ICD-10 15

16 ICD-10 Implementation Affordable Care Act – Section 10109(c) requires the Secretary of HHS to task C&M Committee to obtain input regarding GEMs Make appropriate revisions to GEMs GEM updates discussed at the September 15, 2010 C&M Meeting – ngs.asp ngs.asp 16

17 ICD-10 Implementation Available Updates – ICD-10-CM – ICD-10-PCS – GEMs – Reimbursement Mappings 17

18 ICD-10 Implementation Training Timeline – Intensive coder training should not be provided until 6-9 months prior to implementation – Two full days of ICD-10-CM training will likely be For most coders Proficient ICD-9-CM coders may not need that much 18

19 ICD-10 Implementation Recommendations – Be ready by Jan 1, 2014 for implementation preparation Complete tasks identified during Impact Assessment: Implement Systems Changes Modify or develop – Policies/procedures – Reports – Forms Provide education to users – Other than intensive coder education 19

20 How Can You Prepare? Begin adding the following to physician documentation templates and queries: – Side of dominance Left, right, or ambidextrous (defaults to right) – Laterality All paired organs or structures – Ordinality Is this the initial visit or a subsequent visit for the complaint? Are these symptoms the sequela of the initial event? 20

21 General Considerations What policies and procedures will need revision? – ICD-10-CM/PCS will have new Coding Clinic advice – How will you address decreased productivity during the transition? What templates will need revision? – Operative reports – History and physicals – Query forms 21

22 References/Resources CMS ICD-10 Web site: Medicare Fee-for-Service Provider Resources: Resources.asp Resources.asp Association of Clinical Documentation Improvement Specialists Web site: NHLBI’s National Asthma Education and Prevention Program: Open Fracture: Gustilo Classification: 22

23 Help with Implementation Documentation Issues - NOW Cheat sheets Encounter forms EMR/EHR AAOS products Physician buy in 23

24 Documentation Issue Now How is your group set up? – Do you have billers/coders assigned to a specific provider? – Do you have billers/coders assigned to alphabet of patients? – Who is currently selecting the diagnosis codes? – Do you review the documentation for EM services BEFORE you bill the claim? – Do you review the documentation for the Operative notes BEFORE you bill? 24

25 Billing Staff assigned to given provider Option One – Assigning Billing Staff to a given provider – Example – Mary is in charge of Dr. Sam’s coding and billing. Dr. Sam does mainly shoulders – Example – Mary is also in charge of Dr. Tom’s coding and billing. Dr. Tom does mainly hips 25

26 Option One in more Detail Using the example – If Mary is in charge of two providers – one doing shoulders and one doing hips – Mary can now focus on those ICD-10 codes Working with those providers on their current ICD-9 usages Checking to see if these providers are documenting appropriately – Are they stating right and left in follow-up visits – Are they being specific and not just saying “seeing back postop” or “patient is here in follow up from surgery” – Checking this documentation NOW before ICD-10 comes on board will help smooth the process – and will be better to handle provider-wise 26

27 Downside Option One Billers/Coders must be aware of ALL contacted payers/carrier policies and guidelines Need to have ongoing tracking and checking of contract/reimbursement changes and medical necessity issue changes again for ALL payers 27

28 Option Two Billing staff is assigned based on contracted payer/carrier – Example – Mary does all BCBS; Susan does all Medicaid; Cindy does all Worker’s Comp; Tiffany does all Medicare; etc 28

29 Option Two in more Detail Option Two is a great option for two reasons – One – It means that one or two people are always up on the policies/updates for that contracted payer. Very important for reimbursement issues and especially medical necessity issues (LCDs) – Two – Less chance of leaving $$ on the table as those billers/coders MUST always know when changes take place and not find out 3-6 months later after getting denials 29

30 Downside Option Two In option two, there would be less one- on- one contact with the given provider – but if providers know that Tiffany does the Medicare patients, they would know who to go to. Cross training – there would have to be cross training just in case Mary goes out sick. – Otherwise, who is back up that knows BCBS or where to even look? 30

31 Option Three Billing staff not assigned to a given provider but just does the bills as they come in If this is your arrangement, you might want to see if you can change to Option One or Two without too much fuss 31

32 Downside Option Three Since no one takes responsibility for a given payer/carrier, this can leave practice open to lost revenue Physicians could end up getting different answers to the same question regarding policy/procedures for a given payer. 32

33 Do you have MA, PA, etc? In addition to the billing/coding staff do you have other staff members? Are the MA, PA, etc assigned to a given provider? Example – Sarah MA is assigned to Dr. Sam and Dr. Tom – therefore Sarah MA might be the one assigning the diagnosis codes 33

34 More Documentation Issues Need in EVERY service note being billed: – Right or Left – Specific anatomic location – What kind of injury – What kind of fracture – What kind of trauma – What stage - initial, subsequent, etc. – What is happening – normal healing, delayed healing, nonunion, malunion, sequela 34

35 Documentation Summary Any of the Four options can be used to start this ICD-10 transition and really does not involve the physician YET!! The more we can get in place before bringing physicians on full board will be better Need to start reviewing these notes NOW… 35

36 Cheat Sheets Staff as well as Physicians will need help to get used to these new codes. Having workable ‘cheat sheets’ will go a long way in helping the process Remember, Orthopedic Surgeons are Specialists, so codes need to be HIGHEST specificity – NOT unspecified 36

37 7 th Character Cheat Sheet is a Must Under ICD-10 any fractures or injuries are going to continue to be coded with the acute code and the 7 th character will change Some examples of laminated cheat sheets – front and back 37

38 Injury 7 th Characters A – Initial encounter D – Subsequent encounter S – Sequela Examples – Dislocations, Injury to nerves, muscle, tendons, blood vessels, crush injury, open wounds, etc. 38

39 Fracture 7 th Character A – Initial encounter for closed fracture B – Initial encounter for open fracture type I or II C – Initial encounter for open fracture type IIIA, IIIB, or IIIC D – Subsequent encounter for routine healing E – Subsequent encounter for open fracture type I or II with routine healing F – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC G – Subsequent encounter for fracture with delayed healing H – Subsequent encounter for open fracture type I or II with delayed healing 39

40 Continued Fracture 7 th J – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K – Subsequent encounter for closed fracture with nonunion M – Subsequent encounter for open fracture open fracture type IIIA, IIIB, or IIIC N – Subsequent encounter for open fracture type IIA, IIIB, or IIIC with nonunion P – Subsequent encounter for closed fracture with malunion Q – Subsequent encounter for open fracture type I or type II with malunion R – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - Sequela 40

41 Confusing part on fracture 7 th character…. Not all 7 th character will apply to all fracture codes. Example – – S52 – Fracture Forearm uses all A-S – Exception S52.01X Torus fracture of upper end ulna uses A, D, G, K, P, S – Exception S52.11X Torus fracture of upper end radius A, D, G, K, P, S 41

42 Example Non-traumatic – Slipped acute upper femoral epiphysis right hip – M93.001 Traumatic – Acute or chronic slipped capital femoral epiphysis, traumatic right hip – Initial visit – S79.011A – Subsequent visit normal healing – S79.011D – Subsequent visit delayed healing – S79.011G – Nonunion subsequent visit – S79.011K 42

43 Aftercare Coding issues A patient has a displaced, closed fracture of the greater trochanter of the right femur (S72.111). The following codes would be assigned for this case: – Patient seen in the ER, admitted, and surgery performed: S72.111A, Initial encounter for closed fracture – Seen in the office two weeks after surgery - S72.111D, Subsequent encounter for closed fracture with routine healing – Patient to physician office for follow-up visit and now PRN: S72.111D, Subsequent encounter for closed fracture with routine healing 43

44 Late Effects… Use the “S” Extension S, sequela, is used for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequela of the burn. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The S extension identifies the injury responsible for the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code. Sequela is the new terminology in ICD-10-CM for late effects in ICD- 9-CM and using the sequela extension replaces the late effects categories (905–909) in ICD-9-CM. 44

45 Using Cheat Sheets Can you see where the different Options might work better with these 7 th character issues? If the coder/biller/MA/PA is working just with the Hand surgeon they would need to know the open fracture Type I-IIIC – Most of these open types are for the forearms – The Gustilo open fracture classification for extremities classifies open fractures into three major categories (types) depending on the mechanism of the injury, soft tissue damage, and degree of skeletal involvement 45

46 Gustilo Classifications Open fractures have been classified by Gustilo as follows, with higher numbers indicating more severe injuries: ILow energy wound less than 1 cm IIWound greater than 1 cm with moderate soft tissue damage IIIHigh energy wound greater than 1 cm with extensive soft tissue damage IIIAAdequate soft tissue cover IIIBInadequate soft tissue cover IIICAssociated with arterial injury 46

47 Will your documentation be ready for ICD-10 47

48 Encounter Forms/EMR/EHR How to get ICD-10 to work in your office today – Paper office Encounter forms Billing slips – EMR/EHR office Linkage Codes loaded appropriately 48

49 Encounter form 49

50 Placing ICD-10 on forms With more codes available in ICD-10, it will be hard to place all like on the following slide. Here is an example of shorter ways to get what you need – Shoulder – Hip – Knee 50

51 51 Pelvic/HipCodeLocationScapula FractureCodeLocationHumerus Cont.CodeLocation Sacrum Zone 1 FxS32.11XX Body, displacedS42.11XXRT/LTShaft obliq nondispS42.33XXRT/LT Sacrum Zone II FxS32.12XX Body, NondisplacedS42.11XXRT/LTShaft spiral displaceS42.34XXRT/LT Anterior Wall AcetabS32.41XXRT/LTAcromial process, displacedS42.12XXRT/LTShaft spiral nondispS42.34XXRT/LT Post. Wall AcetabS32.42XXRT/LTAcromial process, nondisplS42.12XXRT/LTShaft comm displaceS42.35XXRT/LT Ant. Column AcetabS32.43XXRT/LTCoracoid process, displacedS42.13XXRT/LTShaft comm nondispS42.35XXRT/LT Post. Column AcetabS32.44XXRT/LTCoracoid process, nondisplS42.13XXRT/LTShaft segment dispS42.36XXRT/LT Pubis superior rimS32.51XXRT/LTGlenoid cavity, displacedS42.14XXRT/LTShaft segment nondS42.36XXRT/LT Ischium avulsionS32.61XXRT/LTGlenoid cavity, nondisplS42.14XXRT/LTCondyle lat, displaceS42.45XXRT/LT Shoulder Neck, displacedS42.15XXRT/LTCondyle lat, nondispS42.45XXRT/LT Contusion, ShoulderS40.01XXRT/LTNeck, nondisplacedS42.15XXRT/LTCondyle med, displS42.46XXRT/LT Open wnd w/FBS41.02XXRT/LTShoulder sprain/strain/tear Condyle med, nondisS42.46XXRT/LT Open wnd w/o FBS41.01XXRT/LTCH ligamentS43.41XXRT/LTTranscond, displacedS42.47XXRT/LT Dislocation Rotator cuff capsuleS43.42XXRT/LTTranscond, nondispS42.47XXRT/LT Anterior, shoulderS43.01XXRT/LTGlenoid LabrumS43.43XXRT/LTTorus lower endS42.48XXRT/LT Posterior, shoulderS43.02XXRT/LTOther ligament shoulderS43.49XXRT/LTHumerus supracond Inferior, shoulderS43.03XXRT/LTAC joint sprainS43.5XXXRT/LTSimple w/o inter dispS42.41XXRT/LT AC jt subluxationS43.11XXRT/LTSC joint sprainS43.6XXXRT/LTSimple w/o inter nonS42.41XXRT/LT AC jt 100-200% dispS43.12XXRT/LTHumerus Comm w/o inter dispS42.42XXRT/LT AC jt > 200% dispS43.13XXRT/LTSurg. neck 2-pt, dispS42.22XXRT/LTComm w/o inter nonS42.42XXRT/LT AC jt inferiorS43.14XXRT/LTSurg. Neck 2pt,nondS42.22XXRT/LTHumerus epicondylar AC jt posteriorS43.15XXRT/LTSurg. Neck 3part dispS42.23XXRT/LTLateral displacedS42.43XXRT/LT SC jt anteriorS43.21XXRT/LTSurg.neck 3part, nonS42.23XXRT/LTLateral nondisplacedS42.43XXRT/LT SC jt posteriorS43.22XXRT/LTSurg.neck 4part, dispS42.24XXRT/LTMedial displacedS42.44XXRT/LT Scapula subluxS43.31XXRT/LTSurg.neck 4part, nonS42.24XXRT/LTMedial nondisplacedS42.44XXRT/LT Scapula dislocationS43.31XXRT/LTGreater troch displS42.25XXRT/LT Clavicle Fracture Greater troch nondS42.25XXRT/LT Sternal, ant displ.S42.01XXRT/LTLesser troch displS42.26XXRT/LT Sternal, post displ.S42.01XXRT/LTLesser troch nondS42.26XXRT/LT Sternal nondispl.S42.01XXRT/LTTorus upper endS42.27XXRT/LT Shaft, displacedS42.02XXRT/LTShaft greenstickS42.31XXRT/LT Shaft, nondisplS42.02XXRT/LTShaft trans. DisplacS42.32XXRT/LT Lateral end, displS42.03XXRT/LTShaft trans. NondisS42.32XXRT/LT Lateral end, nondS42.03XXRT/LTShaft obliq displaceS42.33XXRT/LT

52 Forms As you can see, the forms can be made for specific body parts But all options (besides unspecified) should be available for selection. Can use ‘other specified’ but try to avoid ‘unspecified’ 52

53 Medical Necessity Issues Even more important that you know your contracted payers/carriers policies For Ortho those are: – Trigger points – Total hips and total knees – Spinal Procedures – Intra-articular injections Synvisc, etc. – Spinal Injections Facet Transforaminal SI joint Epidural 53

54 AAOS help CodeX 2013 – Started putting ICD-10 codes to help – “Your 2013 Orthopaedic Code X program will include CPT to ICD – 9 x-refs and CPT to ICD – 10 x-refs. You will be fully prepared to change coding systems on the October 1, 2014 effective date.” CPT/ICD-9/ICD-10 linkage Articles Webinars – Annual Meeting 54

55 AAOE CodeX 2013 screens 55

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64 Now the Physician Piece Be pro-active Start reviewing EM notes NOW – First encounters usually are good – Follow ups are BAD.. Hard to get right/left – Hard to get original injury once surgery done Start reviewing OP notes NOW Let Physicians know that there is no longer aftercare healing codes or late effects codes – will always use the original injury/fracture code all the way through. 64

65 Example Patient returns one year after total left knee arthroplasty – no complaints Z47.1 Aftercare following joint replacement surgery Z96.652 Presence of left artificial knee joint – Use additional code to identify the joint (Z96.6-) 65

66 Example Removal of hardware – Z47.2 Encounter for removal of internal fixation device – Excludes1 – Encounter for adjustment of internal fixation device for fracture treatment, code to fracture with appropriate 7 th character. Encounter for removal of external fixation device – code to fracture with 7 th character D Infection or inflammatory reaction to internal fixation device (T84.6-) Mechanical complication of internal fixation device (T84.1-) 66

67 Summary Auditing notes NOW – Get a base level – then start education – Re-audit after capturing a teaching point Example audit reveals they are not saying right and left on subsequent encounters – Educate they must – Re-audit 2 months later Work through with software vender – Is there a clickable option so provider can remember to check that diagnosis with appropriate 6 th and 7 th characters Do monthly newsletters, meetings taking ICD-10 issues piece by piece – Start small – don’t overwhelm – better to do bit by bit 67

68 Summary Tips Vendor Questions - See form at end of presentation Conduct a business impact and assess the impact on future reimbursement Identify, pursue and collaborate with providers who generate the highest volume of claims Involve Decision Support staff early to assist with analysis and reporting 68

69 Additional Tips Start updating physician query forms/templates NOW and make sure you have a tracking process for queries. Remind physicians - ICD-10-CM is similar to ICD-9-CM, but with greater expansion and specificity. Clinical data is needed and used throughout healthcare for pay for performance, quality, legal aspects, regulatory, reimbursement, research and outcomes. 69

70 Resources AAOS CodeX 2013 ICD-10 guidelines it.aspx Samples of encounter forms 70

71 ICD-10 Guidelines Guideline Resources – The Official ICD-10-CM coding guidelines – Addenda /ICD10CM/2011/ /ICD10CM/2011/ – Some other great resources: group.html group.html group.html group.html 71

72 Question Comments 72

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